Prevalence and Associated Factors of High-Risk Human Papillomavirus Infections among Human Immunodeficiency Virus-Infected Women in Lagos, Nigeria

Background: Given the synergistic relationship between human immunodeficiency virus (HIV) and human papillomavirus (HPV) infections, knowledge of the genotypic prevalence and associated factors of high-risk HPV (HR-HPV) among HIV-infected women is crucial for developing targeted interventions such as appropriate screening tests and effective genotype-specific vaccination. Objectives: We determined the prevalence of any HR-HPV and multiple HR-HPV infections and identified associated factors among a cohort of women living with HIV infections (WLHIV) in Lagos, Nigeria. Methods: This descriptive cross-sectional study analysed the data of 516 WLHIV who underwent cervical cancer screening as part of the COMPASS-DUST study at the HIV treatment centre of Lagos University Teaching Hospital from July 2023 to March 2024. Multivariable binary logistic regression models were performed to explore factors associated with HR-HPV and multiple HR-HPV infections. Results: Among the 516 WLHIV enrolled (mean age, 46.5±7.3 years), the overall HR-HPV prevalence was 13.4% (95% CI, 10.6–16.6), disaggregated as 3.3% for HPV16/18 (95% CI, 1.9–5.2) and 11.6% for other HR-HPV genotypes (95% CI, 9.0–14.7). Nineteen women (3.7%; 95% CI, 2.2–5.7)had multiple HR-HPV genotype infections. Having a recent serum CD4+ cell count ≤560 cells/μL (adjusted OR 3.32; 95% CI 1.06–10.38) and HPV 16/18 genotype infections (adjusted OR 38.98; 95% CI 11.93–127.37) were independently associated with an increased risk of multiple HR-HPV infections. Conclusion: The findings of this study provide valuable insights into the epidemiology of HR-HPV infections and highlight the need for tailored interventions and continuous monitoring. By addressing these challenges through targeted screening, effective ART management, and vaccination programs, we can improve health outcomes and reduce the burden of cervical cancer in this vulnerable population.


Introduction
Human papillomavirus (HPV) infection is a major global health concern, particularly due to its established role in the development of invasive cervical cancer [1].Cervical cancer is a leading cause of cancer-related morbidity and mortality among women worldwide [2], with a disproportionately higher burden in low-and middle-income countries, including Nigeria, where screening and vaccination programs are less accessible [3].
Increasing evidence revealed a higher risk and poorer prognosis of cervical cancer among women with human immunode ciency virus (HIV) compared to the general population.HIV infection exacerbates the risk of acquiring high-risk HPV (HR-HPV) infections due to the immunocompromised state it induces [4].
Therefore, due to impaired immune function, there is an increased susceptibility to persistent HR-HPV infection due to ineffective viral clearance in HIV-infected individuals [5][6][7][8] that leads to the development of cervical intraepithelial neoplasia which can progress to invasive cervical cancer, if left untreated [4,9,10].
Given this synergistic relationship between HIV and HPV infections, knowledge of the genotypic prevalence and associated factors of HR-HPV among HIV-infected women is crucial for developing targeted interventions such as effective genotype-speci c vaccination and appropriate cervical cancer screening tests.Nigeria, the most populous country in Africa, faces signi cant public health challenges related to both HIV and cervical cancer [6,11].Lagos, the most populous state and commercial capital of Nigeria presents a microcosm of these challenges, with a high burden of HIV infection and limited resources for comprehensive cervical cancer screening and prevention [10,12].Despite the signi cant risk of HR-HPV infection, data on its prevalence among women living with HIV (WLHIV) in Lagos is sparse [12,13], thus limiting the ability to effectively design interventions to address this dual burden risk factor of cervical cancer.This study, therefore, aimed to ll this knowledge gap by determining the prevalence of any HR-HPV and multiple HR-HPV infections and identifying associated factors among WLHIV in Lagos, Nigeria.By elucidating these factors, we hope to inform public health strategies and clinical practices that can mitigate the impact of HR-HPV and improve health outcomes for this vulnerable population.

Study design and settings
This is a descriptive cross-sectional analysis of the data of WLHIV who underwent cervical cancer screenings as part of the baseline assessments in the "COMPASS-DUST" study."COMPASS-DUST" is a two-phase study currently ongoing in the HIV treatment centre of the Lagos University Teaching Hospital (LUTH).Details of the study design and procedure are published elsewhere [14].LUTH, the leading public health institution in Lagos State, Southwest Nigeria, serves a population of over 20 million.It primarily functions as a referral centre for various government and private hospitals within Lagos and its neighbouring states.Each month, the LUTH HIV treatment clinic delivers comprehensive care to approximately 9,000 individuals living with HIV in Lagos and the surrounding states of Southwest Nigeria.The clinic also offers integrated reproductive health care to sexually active women with HIV infection such as routine cervical cancer screening with either a Pap smear, HPV DNA testing or visual inspection with acetic acid (VIA) [10].

Eligibility criteria
We included and analyzed the data of n = 516 sexually active WLHIV aged 25-65 years who had their HR-HPV infection status recorded after undergoing pelvic examination and cervical liquid-based cytology (LBC) sample collection for cervical cancer screenings including Pap smear, p16/Ki-67 dual staining and HPV testing, at enrolment in the primary study [15] between July 2023 to March 2024.An HPV testing was conducted by a study pathologist/technician, utilizing HPV DNA target ampli cation by Polymerase Chain Reaction followed by nucleic acid hybridization to detect 14 high-risk HPV genotypes (types 16, 18, 31,33,35,39,45,51,52,56,58,59, 66, and 68) in the LBC samples.Excluded from the study were women with suspicious cervical lesions; those with ongoing or recent pregnancy, those with previous HPV vaccination, those with a prior history of cervical cancer or who have had therapy for benign or malignant cervical lesions, and those who have had hysterectomy.

Extracted variables of interest
Variables extracted for analyses in the dataset included the participant's age in years, number of previous childbirths and vaginal births, body mass index (BMI) in kg/m 2 , marital, educational and employment status, CD4 + cell count and viral load, age at menarche, coitarche and rst pregnancy, menstrual status, use of oral hormonal contraceptive, number of lifetime sex partners, previous sexually transmitted infection (STI) treatment, and history of consumption of alcoholic beverages.BMI was calculated as the participant's weight in kilograms divided by the square of height in meters [16].

Operational de nitions of study outcomes
We assessed four study outcomes: the prevalence of any HR-HPV and multiple HR-HPV infections de ned as the proportion of study participants with at least one HR-HPV genotype infection and more than one HR-HPV genotype infections, respectively; and associated factors of HR-HPV and multiple HR-HPV infections, which are variables collected at baseline in the COMPASS-DUST study [15] that were signi cantly associated with HR-HPV and multiple HR-HPV infections, respectively.

Sample size estimation
Using Fisher's formula [17], we estimated a post-hoc sample size of n = 322 to assess the prevalence of HR-HPV infections and multiple HR-HPV infections in WLHIV based on a type I error rate of 5% at a 95% con dence level of 1.96 and a derived proportion of 24.5% for HR-HPV and 8.2% for multiple HR-HPV infections from an earlier study by Ezechi et al. [12], assuming a missing outcome data or data recording error rate of 5%.We, therefore, included the 516 WLHIV who had their HPV infection status recorded in the primary study [14] in our data analyses.

Statistical analysis
Data analyses were performed using IBM SPSS Statistics for Windows, Version 29.0 (IBM Corporation, Armonk, NY, USA).Continuous variables were tested for normality using the Kolmogorov-Smirnov test with Lilliefors' signi cance correction and descriptive statistics were then computed for the participants' baseline characteristics.Categorical variables were expressed as frequencies and percentages, whereas continuous variables were displayed as mean (± standard deviation).We estimated prevalence at 95% con dence intervals using the Clopper-Pearson exact test.Bivariable and multivariable binary logistic regression models were developed to identify variables associated with any HR-HPV and multiple HR-HPV infections.Age and other variables related to the study outcomes (P < 0.20) in the bivariable analyses were then included in the pool of variables for the multivariable analyses using the backward stepwise approach.An Akaike's Information Criterion (AIC) was calculated continuously, and the nal model step with the lowest AIC was chosen as the best-t model.Associations in the nal model were considered signi cant if P < 0.05.
The age-speci c prevalence rates of HR-HPV infections in WLHIV are shown in Figure 1.There was a trend towards a progressive decline in HR-HPV prevalence with age, with a bimodal peak prevalence seen in women aged 25-39 years (20.0-20.4%)and those in the 50-54 years age group (17.8%).The nadir prevalence was recorded in women aged 45-49 years (9.0%).

Discussion
The ndings from this descriptive cross-sectional study of HIV-infected women enrolled in the COMPASS-DUST study [14] provide signi cant insights into the prevalence and risk factors associated with high-risk human papillomavirus (HR-HPV) infections in this vulnerable population.Our study reveals that one in seven of the participants have HR-HPV infections at baseline while the prevalence of multiple HR-HPV infections was considerably lower, with only one in 27 women affected.None of the baseline participants' factors was associated with HR-HPV infections.However, having a serum CD4+ cell count below 560 cells/µL and a co-infection with either HPV 16 or 18 genotype were signi cantly associated with the detection of multiple HR-HPV infections.
The prevalence of HR-HPV infections (  [20] in two systematic reviews and meta-analyses among HIV infected women in Kenya and developing countries respectively.The higher prevalence rates in these studies may be in uenced by regional variations in HPV epidemiology, variations in the diagnostic methods or sensitivity of HR-HPV detection techniques, temporal differences in the study periods re ecting changes in public health interventions or HIV care, and potential variations in implementation, adherence and e cacy of antiretroviral therapy (ART) across different settings.Notably, our study enrolled only sexually active women on ART with well-controlled HIV who are otherwise healthy, hence, the relatively lower HPV prevalence we recorded.
Our study revealed that 3.7% of the enrolled WLHIV had multiple HR-HPV genotype infections.This prevalence is notably close to the 8.2% reported in a 2014 study among HIV-positive women in a similar geographical setting in Lagos, Nigeria [12].This is, however, at substantial variance from the broader Sub-Saharan Africa regional estimates of 22.6% prevalence reported in a 20-year systematic review of WLHIV [21].These variations in study ndings may be due to regional variations in HPV epidemiology, temporal differences in the study periods re ecting changes in public health interventions or HIV care, and the population characteristics as re ected in our study where only ART adherent and healthy HIV-infected women with well-controlled infections were enrolled.
Similar to the nding by Bogale et al. [20] in 2020, HPV 16 was the most prevalent HPV genotype (20.0%) in our study as reported in most of the existing literature [1,12].This nding was, however, different from a previous review which reported HPV 52 as the most prevalent genotype (26.0%) among HIV-infected women [19].HPV 52 (17.2%) is the second predominant HPV genotype observed in this current study.Our ndings also underscore the predominant presence of HR-HPV types 16, 31, 51, 52, and 58, among which only HPV type 16 is covered by the currently approved and available vaccines (Cervarix and Gardasil) [22,23] adopted for the Vaccine Alliance (Gavi)-supported vaccine roll-out programs in Nigeria which started in October 2023 [24].This further highlights the observations of several other studies reporting a high frequency of non-vaccine HPV types among WLHIV in Sub-Saharan Africa [21], thus, the need to reinforce the implementation of population-based HR-HPV screening programs as a crucial step in preventing cervical cancer among WLHIV across the Sub-Saharan Africa region.The age-speci c prevalence rates of HR-HPV infections among WLHIV, as depicted in our study reveal a distinct trend of decreasing prevalence with increasing age [25][26][27].The high prevalence seen in women aged 25-39 years is consistent with the epidemiological understanding of HR-HPV infections, where younger women tend to have higher prevalence rates due to factors such as higher rates of sexual activity, new sexual partnerships, and potentially less robust immune responses compared to older women [28] while the second peak in the 50-54 years age group may be attributable to factors such as hormonal changes associated with menopause which affect vaginal and cervical epithelium, making it more susceptible to HPV infections [27].Additionally, immune senescence, or the natural decline in immune function with age [29], may contribute to the reactivation or persistence of latent HR-HPV infections in older women.
Our study found no signi cant association between the baseline participant factors and HR-HPV infections, and this lack of association suggests that HR-HPV infections may be widespread across various demographic and behavioural pro les within the population of WLHIV.It also highlights the potential in uence of the immunosuppressive state induced by HIV on the susceptibility to HR-HPV, overshadowing other sociodemographic and behavioural risk factors.However, our study identi ed that speci c factors such as CD4+ cell count below 560 cells/µL and HPV 16 or 18 co-infection were associated with multiple HR-HPV infections.The nding of a signi cantly higher risk of HPV infections among HIV-infected women with a serum CD4+ cell count below 560 cells/µL is consistent with the ndings from previous studies where a higher HR-HPV prevalence was recorded in HIV-infected women with lower CD4+ cell counts [12,30].This is based on the understanding that a lower CD4+ cell count, indicative of more advanced immunosuppression, impairs the body's ability to clear HPV infections, thereby increasing the likelihood of multiple HR-HPV infections [30].This nding emphasizes the importance of maintaining optimal immune function through ART to mitigate the risk of HPV coinfections and their potential complications in WLHIV.Furthermore, the nding of an independent association between HPV 16 or 18 co-infection and multiple HR-HPV infections suggests a synergistic pathogenic mechanism that exacerbates the infection risk and the high oncogenic potential of HPV 16 and 18 responsible for a signi cant proportion of cervical cancers globally [1,31] which underscores the need for extended-spectrum genotype-speci c monitoring and interventions.
The ndings of our study have several important implications.Firstly, they highlight the critical need for regular and comprehensive HPV screening programs in addition to vaccinations among WLHIV.
Secondly, the association between lower CD4+ cell counts, and multiple HR-HPV infections reinforces the importance of effective ART adherence to maintain immune function and reduce the burden of cervical cancer.However, the study has a few limitations.First, as the participating women were enrolled in the urban Lagos metropolis with the exclusion of those living in the slums and suburban areas of Lagos, the study ndings can only be these settings in Lagos.Secondly, due to the crosssectional nature of the study, we are unable to infer causality inference in the observed associations between the identi ed factors and multiple HR-HPV infections.Finally, as the study was conducted in an HIV treatment centre where all the enrolled women were on combined ART, our ndings may not be entirely representative of HIV-infected women who are not taking treatment.

Conclusions
Our study reveals that one in seven enrolled HIV-infected women had HR-HPV infections while one in 27 had multiple HR-HPV infections.None of the baseline participants' factors was associated with HR-HPV infections.However, having a serum CD4+ cell count below 560 cells/µL and a co-infection with either HPV 16 or 18 genotype were signi cantly associated with the detection of multiple HR-HPV infections.These ndings provide valuable insights into the epidemiology of HR-HPV infections and highlight the need for targeted screening, effective ART management, and vaccination programs to improve health outcomes and reduce the burden of cervical cancer in this vulnerable population.

Declarations
Acknowledgements Our deepest gratitude goes to all the participating women and staff of the HIV treatment clinic of the hospital who have contributed to this study.We also appreciate the staff of the Research Management O ce of the College of Medicine, University of Lagos staff for their support in securing the funding for the primary study in this article.
Human ethics and consent to participate for the primary study [14] was granted by the Health Research Ethics Committees of the Lagos University Teaching Hospital (ADM/DSCST/HREC/APP/5443) and College Medicine University of Lagos (CMUL/HREC/07/22/1075).The research was conducted ethically according to the World Medical Association Declaration of Helsinki.Before enrollment, all study participants provided written informed consent, and a rigorous commitment to maintaining the privacy and con dentiality of participants' information was upheld during and after the study's completion.

Consent for publication
Not Applicable.

Figures Figure 1
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Table 1 :
Sociodemographic and clinical characteristics of the HIV-infected women participants (n=516)In the bivariable analyses, variables signi cantly associated with HR-HPV infections based on P<0.20 were recent CD4+ cell count ≤560 cells/µL, rst pregnancy before age 23 years, nulliparity, being economically unengaged, and having previous treatment for sexually transmitted infections.However, following a multivariable analysis, none of these variables were independently associated with HR-HPV infections in WLHIV [Table2].

Table 3 :
Bivariable and multivariable analyses of factors associated with multiple high-risk human papillomavirus infections 13.4%) recorded in our study aligns with existing literature across the world, suggesting that HIV-infected individuals have a high burden of HPV infections [8].This gure is, however, lower than the prevalence of 24.5% reported by Ezechi et al. in 2014 among a predominantly similar population of women in another clinical setting in Lagos, Nigeria, and even much lower than the 42.6% recorded in a recently published study by Traore et al. [18] in Bamako, Mali, and the reported pooled estimates of 64.0% by Menon et al. in 2016 [19] and 51.0% by Bogale et al. in 2020